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 Table of Contents  
LETTER TO EDITOR
Year : 2021  |  Volume : 16  |  Issue : 3  |  Page : 361-363

Colour Doppler ultrasonography of temporal artery in treatment naive takayasu arteritis: A pilot study


1 Department of Clinical Immunology and Rheumatology, Christian Medical College and Hospital, Vellore, Tamilnadu; ONE- Centre for Rheumatology and Genetics, Vadodara, Gujarat, India
2 Department of Interventional Radiology, Christian Medical College and Hospital, Vellore, Tamilnadu; Department of Radiology, Government Theni Medical College and Hospital, Theni, India
3 Department of Clinical Immunology and Rheumatology, Christian Medical College and Hospital, Vellore, Tamilnadu, India
4 Department of Clinical Immunology and Rheumatology, Christian Medical College and Hospital, Vellore, Tamilnadu; Department of Rheumatology and Immunology, JSS Medical College, JSS Academy of Higher Education and Research, Mysore, Karnataka, India
5 Department of Interventional Radiology, Christian Medical College and Hospital, Vellore, Tamilnadu, India
6 Department of Cardiology, Christian Medical College and Hospital, Vellore, Tamilnadu, India

Date of Submission20-Dec-2020
Date of Acceptance12-Feb-2021
Date of Web Publication21-Sep-2021

Correspondence Address:
Dr. Debashish Danda
Department of Clinical Immunology and Rheumatology, Christian Medical College and Hospital, Ida Scudder Road, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/injr.injr_349_20

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How to cite this article:
Shah R, Jothy S, Padiyar S, Subramanian R, Keshava SN, Joseph G, Danda D. Colour Doppler ultrasonography of temporal artery in treatment naive takayasu arteritis: A pilot study. Indian J Rheumatol 2021;16:361-3

How to cite this URL:
Shah R, Jothy S, Padiyar S, Subramanian R, Keshava SN, Joseph G, Danda D. Colour Doppler ultrasonography of temporal artery in treatment naive takayasu arteritis: A pilot study. Indian J Rheumatol [serial online] 2021 [cited 2021 Dec 6];16:361-3. Available from: https://www.indianjrheumatol.com/text.asp?2021/16/3/361/324246



Dear Editor,

Colour Doppler ultrasound is a noninvasive procedure and it is being done to assess disease activity in the carotid and vertebral system in patients of Takayasu arteritis (TA).[1] Sonographic signs of arteritis include wall thickening, luminal stenosis, and luminal occlusion. This is seen more commonly in the common carotid artery and has been described as the "macaroni sign." In TA, the most frequently involved vessels are the aortic arch and its proximal branches. The temporal artery is classically involved in the vasculitic process of giant cell arteritis (GCA). The "halo" sign of temporal arteries is the most characteristic ultrasound finding in GCA. Recently, it has been defined by an Outcome Measures in Rheumatology working group as a "homogenous, hypoechoic wall thickening that is well delineated toward the luminal side and that is visible both in longitudinal and transverse planes, most commonly concentric in transverse scans".[1] The halo sign seen in Doppler has a pooled sensitivity and specificity of 77% and 96%, respectively, as compared with the clinical diagnosis of GCA.[2] The ultrasound image of the wall thickening in patients with Takayasu arteritis is brighter than that of temporal arteritis. The reason may be because temporal arteritis is a much more acute disease than TA, resulting in more mural oedema, which results in the darker image.[3] As TA is also a large vessel vasculitis and temporal arteries, being the terminal branches of the external carotid artery may reflect the disease activity in the aorta and other major vessels. Based on this hypothesis, we designed a study to explore any possible involvement of the temporal artery in TA on Color Doppler ultrasonography.

In this pilot prospective study, ten patients, who were seen in the Department of Clinical Immunology and rheumatology and department of cardiology at Christian Medical College Hospital, Vellore during the period between October 2011 and June 2012 were included. All the patients were treatment-naive and had an unequivocal diagnosis of TA based on the ACR 1990 Classification criteria for TA. All had angiographically-proven large vessel involvement. Patients without the angiographic study of arch vessels and patients on steroids or any other immunosuppressant were excluded from the study. We also studied ten age- and sex-matched controls from normal population. Colour Doppler ultrasonography was performed with a 5–11 MHz linear probe (Machine: Toshiba-Xario). The choice of the probe frequency was based on the previous studies published.[4] We used the following settings for our study: Color gain 40, filter 3, dynamic range 60, and 2D gain 82–91. The Colour scale was adjusted between 8–20 cm/s. We examined bilateral common superficial temporal arteries and the frontal and parietal rami as completely as possible in the longitudinal and transverse plane to look for a hypoechoic halo around the lumen and whether there was any stenosis. Stenosis was considered to be present if peak systolic velocity was more than twice that recorded in the area preceding the stenotic segment. Proximal parts of frontal and parietal rami were always evaluated.

All the patients had disease onset at or before 40 years of age (female: male - 8:2). Limb claudication was the most common complaint at onset and at the time of the study (5 cases). Three cases had secondary hypertension detected at disease onset which is a sequel of TA in this young cohort. Diabetes, dyslipidemia, or other comorbidities were not seen in any case. Type V was the most common angiographic type observed (50%). The coronary artery was involved in two cases. All the cases had active disease on presentation with median ITAS (Indian Takayasu Activity score) of 5 (range 2–11). The median (range) C-reactive protein was 7.55 (2–69) mg/L. The demographic characteristics have been tabulated in [supplemenatry Table 1].



Hypoechoic halo was not seen in ultrasonographic study of the temporal artery in any of the ten cases or controls [Figure 1]a, [Figure 1]b, [Figure 1]c, [Figure 1]d. [Table 1] shows the peak systolic blood-flow velocity along the common superficial temporal artery and its parietal and frontal branches in the cases and control groups, respectively. As per the literature, unilateral halo sign has an overall sensitivity of 68% (95% confidence interval [CI], 0.61–0.74) and specificity of 91% (95% CI, 0.88–0.94) for GCA.[5] Halos disappear after a median of 16 days (Range 7-56 days) of corticosteroid therapy in GCA cases.[4] None of our cases had received steroid or any other immunosuppressant before enrolment for the study. Ultrasonography is 87% sensitive in diagnosing temporal arteritis with regard to clinical diagnosis.[6] This fact has to be borne in mind when we look at the negative results in our study on TA.
Figure 1: (a and b) Longitudinal and cross sectional color Doppler images and spectral pattern of frontal ramus of the left temporal artery in a case. (c and d) Similar study image of a control subject. Observed peak systolic velocity values suggest the absence of stenosis along the studied part of the arterial lumen. Parietal ramus could not be visualized in a case (left side) and in a control (right side)

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Table 1: Color Doppler ultrasonography findings in temporal artery of Takayasu's arteritis cases

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Although we used a probe frequency of 5–11 MHz, nowadays probes with ≥15 MHz frequency are increasingly being used to detect minor wall thickening.[7] In our study, we observed non traceable parietal ramus in one subject from the cases and one from the control group. Tardus spectral pattern in left superficial temporal artery was observed in one subject from our case group, which can be explained by significant stenosis of common carotid artery in that patient.

Although Takayasu's and GCA are comparable in some ways on histopathological studies of large vessels, our study did not demonstrate Doppler ultrasonographic findings in temporal arteries of patients with TA unlike that in a large proportion of cases with GCA as reported in literature. Ethnic differences, age at disease onset, specific predilection for vessel involvement and lack of temporal artery involvement by our Doppler study may suggest that TA is a different disease than GCA. This may also imply different pathogenic pathways leading to unique disease manifestations in each entity, rather than the different manifestations of the same entity.


  Acknowledgment Top


We are thankful to our patients for their co-operation and for agreeing to be part of our study.

Financial support and sponsorship

Fluid grant from Christian Medical College and Hospital, Vellore, India. EC name: Christian Medical College Vellore Institutional Review Board IRB Number and date of approval : 7420 dated 22.02.2011.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Schmidt WA, Nerenheim A, Seipelt E, Poehls C, Gromnica-Ihle E. Diagnosis of early Takayasu arteritis with sonography. Rheumatology (Oxford) 2002;41:496-502.  Back to cited text no. 1
    
2.
Chrysidis S, Duftner C, Dejaco C, Schäfer VS, Ramiro S, Carrara G, et al. Definitions and reliability assessment of elementary ultrasound lesions in giant cell arteritis: A study from the OMERACT Large Vessel Vasculitis Ultrasound Working Group. RMD Open 2018;4:e000598.  Back to cited text no. 2
    
3.
Duftner C, Dejaco C, Sepriano A, Falzon L, Schmidt WA, Ramiro S. Imaging in diagnosis, outcome prediction and monitoring of large vessel vasculitis: A systematic literature review and meta-analysis informing the EULAR recommendations. RMD Open 2018;4:e000612.  Back to cited text no. 3
    
4.
Schmidt WA, Kraft HE, Vorpahl K, Völker L, Gromnica-Ihle EJ. Color duplex ultrasonography in the diagnosis of temporal arteritis. N Engl J Med 1997;337:1336-42.  Back to cited text no. 4
    
5.
Arida A, Kyprianou M, Kanakis M, Sfikakis PP. The diagnostic value of ultrasonography-derived edema of the temporal artery wall in giant cell arteritis: A second meta-analysis. BMC Musculoskelet Disord 2010;11:44.  Back to cited text no. 5
    
6.
Schmidt WA. Technology Insight: The role of color and power Doppler ultrasonography in rheumatology. Nat Clin Pract Rheumatol 2007;3:35-42.  Back to cited text no. 6
    
7.
Schmidt WA. Ultrasound in the diagnosis and management of giant cell arteritis. Rheumatology (Oxford) 2018;57:ii22-31.  Back to cited text no. 7
    


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